Cases corner – 8 year old boy with a rash

8th December 2020

An 8 year old boy presents to you with his mum, with a 2-day history of a spreading rash over his lower limbs. He is otherwise well with no other symptoms. There is no evidence of confusion, neck stiffness, photophobia or fever. He has previously been fit and well and is up to date with his immunisations. His observations are all within the normal range. You examine his lower legs and see the following rash on his feet and legs. Otherwise, the examination is unremarkable.

What would you do next?

  1. Reassure his mum and offer safety-netting advice if he deteriorates
  2. Refer the patient for an urgent full blood count (within 48 hours)
  3. Refer the patient for a full blood count (within 2 weeks)
  4. Consider urgently referring the patient to a specialist within 48 hours
  5. Refer the patient immediately to hospital

All Children and young people presenting with unexplained petechiae or hepatosplenomegaly should be referred for immediate specialist assessment for leukaemia

This is a new recommendation as part of the cancer referral guidelines. The boy has presented with a petechial, non-blanching rash over his lower limbs which his mum has reported spreading. There are a range of differential diagnoses that may concern you; in particular meningitis. However, the child is afebrile and systemically well. Many may feel that urgent referral may be unnecessary, and would choose to organise an urgent blood test in primary care in order to assess the child further or may decide to review the child later that day or the next day.

However, childhood leukaemia is a life-threatening condition where a delay of even a few days could significantly impact the prognosis and patient’s outcome. The paediatric team would likely do a whole host of tests and investigations, beyond the routine ones available in primary care. The safest place for the patient is in the hospital where leukaemia can be ruled out, or if necessary, the child’s care can be escalated – often to a tertiary centre. In the majority of cases, children with leukaemia commence treatment within 24 to 48 hours following a diagnosis. Avoiding any delays to treatment can be life saving for the patient.